L29212-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Laser Treatment for Psoriasis (L29212)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29212

LCD Title Laser Treatment for Psoriasis

Contractor's Determination Number 96920

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See § 1869 (f)(1)(A)(i) of the Social Security Act.

Unless other wise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-03, National Coverage Determination, Chapter 1, Section 250.1

Indications and Limitations of Coverage and/or Medical Necessity

Psoriasis is a common chronic recurrent disease of the skin that is characterized by dry, well circumscribed, silvery, scaling papules and plaques of various sizes. The severity of psoriasis can vary from one or two lesions to a widespread dermatosis with disabling arthritis and exfoliation. Psoriasis commonly involves the scalp, the exterior surface of the extremities (particularly at the elbows and knees), the back, and the buttocks. The nails, eyebrows, axille, umbilicus or anogenital region may also be affected. The exact cause of psoriasis is unknown, and there is no known cure for the disease. Most patients with psoriasis have a mild to moderate form of the disease (10% or less of the total body surface area affected). The effective use of photochemotherapy (PUVA) and ultraviolet light therapy (UVB) in the treatment of psoriasis is well documented in the medical literature. The 308-nanometer (nm) excimer laser uses a XeCl gas mixture to generate an ultraviolet laser light source of UVB radiation that can concentrate energy solely on a psoriasis plaque and avoid damage to surrounding healthy skin.

This concentrated UVB allows for higher treating dosages of ultraviolet light than that using general UVB or PUVA. The 308-nm excimer laser has been shown to be an effective treatment in clearing plague type psoriasis.

Medicare will consider the use of the 308-nm excimer laser medically necessary and reasonable for the treatment of psoriasis in patients who have met all of the following criteria:

• mild to moderate plaque type psoriasis, defined as 10% or less of the total body surface area affected,

• psoriasis plaques have been present and unchanged for a minimum of two months,

• total surface area to be treated is 10% or less of the total body surface.

• the laser treatment device must meet Food and Drug Administration (FDA) approval for the treatment of psoriasis.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

96920 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); TOTAL AREA LESS THAN 250 SQ CM

96921 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); 250 SQ CM TO 500 SQ CM

96922 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); OVER 500 SQ CM

ICD-9 Codes that Support Medical Necessity

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the treating provider must substantiate the medical necessity of the services being billed. In addition, documentation that the service was performed must be included in the patient’s medical record. This information is normally found in the history and physical, office/progress notes, hospital notes, and/or procedure report.

Documentation must support the criteria for coverage as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to medical review.

Although the length of remission from psoriasis may vary based on the individual response to the treatment, it is not expected that a single course of treatment would be performed more than once in a four-month period

A single course of treatment is limited to 10 sessions per target area generally performed over the span of three to four weeks. The treatment target area will be no more than 10% of the total body surface area. Due to the nature of this condition, treatment may involve one single site, or encompass several sites that collectively equal 10% or less.

Sources of Information and Basis for Decision

Feldman, S., Mellen, B., Salam, T., Fitzpatrick, R., Geronemus, R., Vasily, D., and Morison, W., (2001). The efficacy of 308-nm lasers treatment of psoriasis compared to historical controls. Dermatology Online Journal 7(2). Available: http//:ucdavis.edu/doj. This source was used to provide indications and limitations for use of the device.

PhotoMedix (2002). Use of the photomedex xtrac system for the treatment of mild to moderate psoriasis. Carlsbad, CA: Author. This source was used to provide a description of the laser device.

Rodewald, E. J., Housman, T.S. Mellen B.G., Feldman, S.R. (2002). Follow-up survey of 308 nm laser treatment for psoriasis. Lasers in Surgical Medicine, 31, 202-206. This source was used to provide limitations and utilization guidelines.

Trehan, M., & Taylor, C.R., (2002). Medium-dose 308-nm excimer laser for the treatment of psoriasis. Journal of American Academy of Dermatology, 47, 701-708. This source was used to provider indications for medical

necessity. Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29212) replaces LCD L13843 as the policy in notice. This document (L29212) is effective on 02/02/2009.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

96920 descriptor was changed in Group 1 96921 descriptor was changed in Group 1 96922 descriptor was changed in Group 1

Reason for Change